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SAN JOAQUIN LOQ?�iL I VLTH DISTRICT <br /> FOYP"Z?FP DE USE F`' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . <br /> Telephone: ' (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z_ 9 I O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date Issued _ F- 7 Z" <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / . CENSUS TRACT ' <br /> Owner's Name r Phone <br /> Addressa City <br /> Contractor's Name a License # 12373 Phone -S <br /> TYPE OF WORK (Check): NEW WELL '/ / DEEPEN '/ / RECONDITION /-7. DESTRUCTION /7 <br /> PUMP INSTALLATION '/_/ PUMP REPAIR LX/ PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Other Rotary Type of Grout i <br /> Other Other Information _ I <br /> V <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ,� �� f Gj; TITLE _ <br /> (DRAW PLO PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> 4/72 1M <br /> E H 1426 <br /> 1 r <br />